STATE OF INDIANA COUNTY OF IN RE THE MARRIAGE OF: ) IN THE ) SS: ) CASE NO. SUPERIOR/CIRCUIT COURT Petitioner, V. VERIFIED MOTION FOR FEE WAIVER Respondent. The Petitioner now states: 1. I wish to file this action and I believe that I have a case with merit. 2. I cannot pay any of the filing fees or other costs of this action because I do not have sufficient income or resources. 3. I live with ___________________________________________________________________. 4. Our family's income is ____________ per month. (Total from below) (Income received each month, before taxes) Wages (_______ per hour x ________ hours per month) Unemployment Compensation AFDC / TANF Benefits SSI / SSD Benefits Child Support Other + Total = We have ____________ in the bank. Our expenses total ____________ per month: (Total from below) (Expenses spent each month) Housing (Rent, Contract, or Mortgage) Utilities (Gas, Electric, Water, Phone, etc.) Food Child Care Medical Bills Transportation Insurance (car, medical and/or property) Child Support Other (please describe) + _______________________________ Total = ____________ ____________ ____________ ____________ ____________ ____________ ____________ 5. 6. ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ I request that this Court waive all costs of this action and allow me to proceed without the payment of any filing fees or other costs. I affirm under the penalties of perjury that the foregoing representations are true. _____________________________ Signature Page 1 of 1 Form PS-33373-1 Revised by State Court Administration 10/10 American LegalNet, Inc. www.FormsWorkFlow.com